Winning Social Security Disability Benefits for Schizophrenia by Meeting a Listing

To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your schizophrenia is severe enough to meet or equal the schizophrenia listing. The Social Security Administration has developed rules called Listing of Impairmentsfor most common impairments. The listing for a particular impairment describes a degree of severity that Social Security Administration presumes would prevent a person from performing substantial work. If your schizophrenia is severe enough to meet or equal the listing, you will be considered disabled.

The Listing for schizophrenia is 12.03. It has 3 parts: A, B, and C. To meet the listing, you must satisfy both parts A and B or just part C alone. You do not have to be in the active phase of psychosis to qualify under this listing.

To meet part A of the schizophrenia listing, you must have medically documented persistence, either continuous or intermittent, of one or more of the following:

1. Delusions or hallucinations; or

2. Catatonic or other grossly disorganized behavior; or

3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech if associated with one of the following:

a. Blunt affect; or

b. Flat affect; or

c. Inappropriate affect;

or

4. Emotional withdrawal and/or isolation.

Part A requires persistent abnormalities. Persistent does not mean that the abnormality has to be present all the time. Intermittent presence of the abnormality is sufficient, as specific abnormalities may be present in greater or lesser degree depending on the phase of the illness (see Phases of Schizophrenia), partial suppression by medications (see Side Effects of Schizophrenia Medications), and the severity of psychosocial stressors.

Part A.1 Hallucinations or Delusions

Part A.1 requires hallucinations or delusions. A hallucination is a false sensory perception; it is a sensory experience generated within the brain itself, rather than as a result of input from the stimulation of a sensory organ. Hallucinations may be experienced as inside or outside of the body. Any of the senses may be involved, e.g., visual, auditory, gustatory (taste), olfactory (smell), tactile, or somatic (apparent sensations from inside the body). A person having a hallucination may or may not recognize its unreality. Auditory hallucinations (e.g., hearing voices) are most common in schizophrenia.

A hallucination is not the same thing as an illusion. An illusion, rather than a hallucination, occurs if a person misunderstands or misperceives an actual sensory stimulus. Perceptions experienced while falling asleep, dreaming, or in the process of awakening are not considered hallucinations. A hallucination alone does not mean the person has a mental disorder. A person may experience hallucinations without being mentally ill.

A delusion is an abnormality of thought content; it is a false belief that is maintained despite clear evidence to the contrary. The most common delusions in schizophrenia involve various beliefs that one’s thoughts are broadcast so that they can be heard by others; that one is being persecuted by others in some special personal way; that thoughts can be removed from one’s head by other people; or that one is controlled by some outside agency acting upon one’s mind directly and by force. However, the delusions may be of any type.

Part A.2 Catatonic or Other Grossly Disorganized Behavior

Part A.2 is fulfilled by “catatonic or other grossly disorganized behavior.” Catatonia is an extreme example of disorganized behavior, ranging from excited purposeless activity to a stuporous state. Catatonia may involve rigid or bizarre posturing of the body. Catatonia is not the only form of disorganized behavior that qualifies. If a person’s behavior is so disorganized that rational, goal-directed activity is missing, then that is also sufficient to fulfill part A.2.

Part A.3 Incoherence, Loosening of Associations, Illogical Thinking, or Poverty of Speech Content

Part A.3 describes a number of abnormalities. Any one of these in conjunction with one of the subparts (a) (blunt affect), (b) (flat affect), or (c) (inappropriate affect) is sufficient.

Incoherence is a defect in communication characterized by speech that cannot be understood in a rational way. The pattern of meaning found in rational speech is lacking, and even the rules of grammar may be distorted.

Loosening of associations is a thought defect, in which ideas shift inappropriately from one subject to another, showing a lack of rational connectedness of which the person is unaware. Incoherence represents an even more severe defect in the form of thought.

Illogical thinking is a defect in the content of thought in which clearly erroneous conclusions are reached from given presumptions or data, and can be closely linked to a delusional system.

Poverty of content of speech represents an abnormality in the content of thought, in that very little information with meaningful content can be gained from listening to such speech. (Poverty of the content and quality of speech is known as alogia.)

In blunt affect, emotional responsiveness is decreased. In flat affect, emotional responsiveness is absent. In inappropriate affect, emotional responsiveness is present but not rationally connected to a person’s speech or thoughts.

Part A.4 Emotional Withdrawal or Isolation

Part A.4 requires emotional withdrawal or isolation. Isolation and withdrawal are frequent features of schizophrenia. In the extreme condition, the person may become autistic with a seemingly complete lack of awareness of his or her environment. Many severe abnormalities of perception and thinking in schizophrenia produce confusion in self-identity and relationship to the outside world. Reality-testing breaks down, and di
sorganized behavior replaces purposeful activity and/or the purpose has an illogical or delusional basis.

Emotional withdrawal and isolation follow in response to an incomprehensible world and self. Or another way of looking at things is that the physiological processes of the brain are too disrupted to allow a normal level of interaction with the world. Suspiciousness and delusions tend to produce isolation and withdrawal also, as this may decrease the feeling of vulnerability the person feels.

To meet the schizophrenia listing, you must satisfy the requirements of part A and, as a result of those impairments have at least two of the following:

1. Marked restriction of activities of daily living; or

2. Marked difficulties in maintaining social functioning; or

3. Marked difficulties in maintaining concentration, persistence, or pace; or

4. Repeated episodes of decompensation, each of extended duration.

Information Needed to Assess Part B

Here is what Social Security Administration says about the information needed to assess whether part B of the listing is met:

Assessment of Severity: We measure severity according to the functional limitations imposed by your medically determinable mental impairment(s). We assess functional limitations using the four criteria in paragraph B of the listings: activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation. Where we use “marked” as a standard for measuring the degree of limitation, it means more than moderate but less than extreme. A marked limitation may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with your ability to function independently, appropriately, effectively, and on a sustained basis. See §§404.1520a and 416.920a.

1. Activities of daily living include adaptive activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for your grooming and hygiene, using telephones and directories, and using a post office. In the context of your overall situation, we assess the quality of these activities by their independence, appropriateness, effectiveness, and sustainability. We will determine the extent to which you are capable of initiating and participating in activities independent of supervision or direction.

We do not define “marked” by a specific number of activities of daily living in which functioning is impaired, but by the nature and overall degree of interference with function. For example, if you do a wide range of activities of daily living, we may still find that you have a marked limitation in your daily activities if you have serious difficulty performing them without direct supervision, or in a suitable manner, or on a consistent, useful, routine basis, or without undue interruptions or distractions.

2. Social functioning refers to your capacity to interact independently, appropriately, effectively, and on a sustained basis with other individuals. Social functioning includes the ability to get along with others, such as family members, friends, neighbors, grocery clerks, landlords, or bus drivers. You may demonstrate impaired social functioning by, for example, a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or social isolation. You may exhibit strength in social functioning by such things as your ability to initiate social contacts with others, communicate clearly with others, or interact and actively participate in group activities. We also need to consider cooperative behaviors, consideration for others, awareness of others’ feelings, and social maturity. Social functioning in work situations may involve interactions with the public, responding appropriately to persons in authority (e.g., supervisors), or cooperative behaviors involving coworkers.

We do not define “marked” by a specific number of different behaviors in which social functioning is impaired, but by the nature and overall degree of interference with function. For example, if you are highly antagonistic, uncooperative, or hostile but are tolerated by local storekeepers, we may nevertheless find that you have a marked limitation in social functioning because that behavior is not acceptable in other social contexts.

3. Concentration, persistence and pace refer to the ability to sustain focused attention and concentration long enough to permit the timely and appropriate completion of tasks commonly found in work settings. Limitations in concentration, persistence, or pace are best observed in work settings, but may also be reflected by limitations in other settings. In addition, major limitations in this area can often be assessed through clinical examination or psychological testing. Wherever possible, however, a mental status examination or psychological test data should be supplemented by other available evidence.

On mental status examinations, concentration is assessed by tasks such as having you subtract serial sevens or serial threes from 100. In psychological tests of intelligence or memory, concentration is assessed through tasks requiring short-term memory or through tasks that must be completed within established time limits.

In work evaluations, concentration, persistence, or pace is assessed by testing your ability to sustain work using appropriate production standards, in either real or simulated work tasks (e.g., filing index cards, locating telephone numbers, or disassembling and reassembling objects). Strengths and weaknesses in areas of concentration and attention can be discussed in terms of your ability to work at a consistent pace for acceptable periods of time and until a task is completed, and your ability to repeat sequences of action to achieve a goal or an objective.

We must exercise great care in reaching conclusions about your ability or inability to complete tasks under the stresses of employment during a normal workday or workweek based on a time-limited mental status examination or psychological testing by a clinician, or based on your ability to complete tasks in other settings that are less demanding, highly structured, or more supportive. We must assess your ability to complete tasks by evaluating all the evidence, with an emphasis on how independently, appropriately, and effectively you are able to complete tasks on a sustained basis.

We do not define “marked” by a specific number of tasks that you are unable to complete, but by the nature and overall degree of interference with function. You may be able to sustain attention and persist at simple tasks but may still have difficulty with complicated tasks. Deficiencies that are apparent only in performing complex procedures or tasks would not satisfy the intent of this paragraph B criterion. However, if you can complete many simple tasks, we may nevertheless find that you have a marked limitation in concentration, persistence, or pace if you cannot complete these tasks without extra supervision or assistance, or in accordance with quality and accuracy standards, or at a consistent pace without an unreasonable number and length of rest periods, or without undue interruptions or distractions.

4. Episodes of decompensation are exacerbations or temporary increases in symptoms or signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing activities of daily living, maintaining social relationships, or maintaining concentration, persistence, or pace. Episodes of decompensa
tion may be demonstrated by an exacerbation in symptoms or signs that would ordinarily require increased treatment or a less stressful situation (or a combination of the two). Episodes of decompensation may be inferred from medical records showing significant alteration in medication; or documentation of the need for a more structured psychological support system (e.g., hospitalizations, placement in a halfway house, or a highly structured and directing household); or other relevant information in the record about the existence, severity, and duration of the episode.

The term repeated episodes of decompensation, each of extended duration in these listings means three episodes within 1 year, or an average of once every 4 months, each lasting for at least 2 weeks. If you have experienced more frequent episodes of shorter duration or less frequent episodes of longer duration, we must use judgment to determine if the duration and functional effects of the episodes are of equal severity and may be used to substitute for the listed finding in a determination of equivalence.

Providing the Social Security Administration With Adequate Information

It is not easy for the Social Security Administration adjudicator to obtain quality, detailed information for use in part B of the listing. Treating psychiatrists often will not provide actual treatment records and when they do, the records often lack the detail needed to make an accurate determination regarding daily activities, social functioning, or concentration, persistence or pace. Medical records are more likely to document part B.4 (repeated episodes of decompensation), because treatment notes or hospitalization records will record a change in the claimant’s condition.

The best evidence of functional ability comes from the claimant’s family or other caregivers, because they actually observe the claimant’s limitations and abilities, unlike the treating doctor. The doctor often merely guesses based on the claimant’s clinical condition.

Most psychiatrists and psychologists have only a general knowledge of their patient’s functional activities. But the treating doctor’s answers to questions about functional limitations may not always help the claimant. For example the doctor may be asked whether a claimant is limited in ability to perform a particular activity like take public transportation. If the doctor answers “Not that I know of,” this answer indicates ignorance and should not be taken as evidence of ability. But if the doctor answers, “I know of no mental limitation that would restrict the claimant’s ability to take public transportation,” then that informs Social Security Administration that the doctor thinks the claimant has the ability, even though the doctor may have no direct information to that effect.

Often, the Social Security Administration adjudicator will try to use daily activity, social information, etc., from a mental status consultative examination. This information often lacks enough detail for good disability determination.

It is important for the adjudicator to try to obtain a detailed specific description of daily activities, social functioning, task completion (concentration, persistence, or pace) and the circumstances surrounding episodes of decompensation. This means documentation of as many specific examples as possible; generalizations such as “He cannot do anything” are worthless. The daily activity forms that claimants or their caregivers complete are rarely specific enough to be of much use. To get high-quality information, the adjudicator must often contact the claimant or caregivers. This is a grueling, time-consuming job that requires an hour or more of communication. Furthermore, disability examiners have no skills in psychiatric interviewing even when they do attempt to get detailed information regarding part B, so that is an additional source of error. Therefore, inadequate development of part B information by the Social Security Administration in mental disorder claims is a weak spot and one reason by a claimant may be denied disability benefits.

If you do not meet parts A and B of the listing, you will be disabled if you meet part C. Part C requires a medically documented history of a chronic schizophrenic, paranoid, or other psychotic disorder of at least 2 years’ duration that has caused more than a minimal limitation of your ability to do basic work activities, with symptoms or signs currently attenuated (lessened) by medication or psychosocial support, and one of the following:

1. Repeated episodes of decompensation, each of extended duration; or

2. A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or

3. Current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.

Proper evaluation under part C of the listing can require a lot of time and effort by the Social Security Administration adjudicator. For the same reasons as given in the discussion of part B, underdevelopment of evidence for part C is something that your Social Security disability attorney should always consider if your application for disability benefits is denied. See Providing the Social Security Administration With Adequate Information.

Part C.1 Decompensation Episodes

Part C.1 requires medical records—records from a medical care facility or from the treating physician that document repeated episodes of significant clinical worsening (decompensation). Worsening could be in any of the areas described under part B of the listing.

Part C.2 Deterioration in Minimally Stressful Conditions

Part C.2 requires deterioration under conditions that would be minimally stressful for a normal person. While medical records documenting the claimant’s decompensation with a minimal change in environment are desirable, family members, friends, and caregivers can be sources of evidence. In fact, statements in a claimant’s medical records about decompensation are probably based on information given to the treating physician by family members. However, the testimony of family and friends is more believable if decompensation was documented in the claimant’s medical records before he or she applied for disability benefits. Then any question about the testimony being self-serving is removed.

There are many possible ways in which change in environment can satisfy part C.2. For example, the claimant might exhibit:

Increased withdrawal when guests other than family members come to dinner,

Emotional outbursts when not permitted to watch a favorite TV show,

Increased confusion when some routine of life is interrupted,

Increased irritability when having to travel outside of the house such as a trip to the dentist, or

Undue frustration and sadness when unable to accomplish some new task.

Part C.3 Need for Highly Supportive Living Arrangement

In part C.3, the “highly supportive living arrangement” could be the claimant living with family members, or living in some other kind of arrangement where there is close supervision. In these instances, the Social Security Administration needs to obtain evidence from the treating physician and other health providers (e.g., nurses), and family member statements that
shows the claimant needs a highly-supervised lifestyle despite only moderate severity in the areas described in part A of the listing.

The easiest way to accomplish this task is to look at the evidence over time to document whysuch a highly supportive living arrangement became necessary. Typically, family members will describe behavioral events that made the claimant unmanageable outside of a closely supervised environment. For example, the claimant may have attempted to stay with family members only to continually wander off and get lost, or have uncontrollable emotional outbursts of anger, or otherwise be unable to cope. While a home environment is acceptable for purposes of part C.3, some families simply do not have the resources and time to adequately care for someone requiring close supervision. However, institutionalization is not in itself a sufficient basis for assuming inability to function outside of a special supportive environment.

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